Scales, Harold Form VB.fa. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ft This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATK OF
_
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.__.._ . .... ....__
Village Dist. No 3294 County ONEIDA or City MARCY
(If city, give street address)
Name of deceased Harold Scales Veteran
(If veteran give acne of war)
Single, married, widowed,
Sex Ma]..Q Color Wh?.i .or divorced (write the word) married Date of Death 4.. 4J/ 19.fji.t:
Age Mr. ea s Mo ths.. ..J...Q. �.D�ays� � Bi lace. Glens Fall , P eyr„`o
Cause of Death` ® � 0 _- c� V C9—" 0 a'l--c;
Certificate was si e�� .' VYN.:
Address. y t..�lt�n.: 5),14-kr-yM.D.
Place of Burial (or Remo al) . ....... .,
(IP body le to be temporariley ti,fill in sync r)
Cemetery .. ,,y.. . �-:_< -. j �,'?--e,; / Date of Burial ,..r l 19/
(If body la to be tempor ly held, e11 in apace later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the bare stated Registered
Number, ron the basisthereof I H REBY GRANT A PERMIT —
.,4-,Z-- d-:—..4"., ,....":„ .."
( (a4d�a.
the ,7-- ',------ .........................._..to hold temporarily a d k:,-� - - the body.
(Undertaker or person having charge of corpse) (Inter,remove, r othe wine d os [state howl)
Dated 19 (Signed) t ' -� ------
Local R
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
` ARE MADE
Date of-; '-` was 19
(
(Interment or )
C77e
:'
(Name of Cemetery, Crematorium, etc.)
Section Lot No. l(1 7 Grave No. /
(Signed) _ •
a.F
(Perron--ta•ehar
Address rL G'1 G
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the face of the Permit the words
"No person in charge," and FILE PERMIT WITHIN THREE
(3) DAYS with the Registrar. of District in which
cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE.
The law will be enforced. Local Registrars are re—
quired, under penalty, to report violations thereof.